NCC233054_FRO Submitted_20231011

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
Part A.
1. Project Name FY20 Short Water Line Extensions Project Phase 2
2. Location of land-disturbing activity: County Union City or Township Indian Trail
Highway/Street Shaftwood Dr Latitude 35° 7'55.09"N Longitude 80°36'27.09"W
Highway/Street Deepwood PI Latitude 35° 7'42.17"N Longitude 80°36'32.54"W
Highway/Street Private Drive off Secrest Short Cut Rd Latitude 35° 3'41.63"N Longitude 80°35'59.46"W
Highway/Street G B Hill Rd Latitude_35° 3'34.47"N Longitude_80°28'58.36"W
Highway/Street Rilla Hamilton Rd Latitude 35° 3'44.39"N_Longitude 80°28'53.63"W
Highway/Street Private Dr off Rilla Hamilton Rd Latitude 35° 3'42.06"N Longitude 80°28'35.51"W
Highway/Street Morgan Mill Rd Latitude 35° 3'44.29"N_Longitude 80°29'7.06"W
Highway/Street_Watson Church Rd_Latitude_35° 5'35.74"N Longitude_80°26'55.67"W_
Highway/Street_Love Mill Rd Latitude_34°58'37.64"N Longitude_80°21'34.53"W
3. Approximate date land-disturbing activity will commence: September 2020
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Municipal
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas): 5.75 Acres
6. Amount of fee enclosed: $ 390.00 . The application fee of$65.00 per acre(rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name John Shutak, P.E. E-mail Address lohn.shutak(a�unioncountync.gov
Telephone [phone] Cell # [phone] Fax# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Union County& NCDOT Rights-of-Way [phone] [phone]
Name Telephone Fax Number
500 N. Main St., Suite 600 500 N. Main St., Suite 600
Current Mailing Address Current Street Address
Monroe NC 28112 Monroe NC 28112
City State Zip City State Zip
10. Deed Book No. Page No. Provide a copy of the most current deed.
Part B.
1. Company (ies) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company or firm is a sole
proprietorship the name of the owner or manager may be listed as the financially responsible party.
Union County John.shutak(r7unioncountync.gov
Name E-mail Address
500 N. Main St., Suite 600 500 N. Main St., Suite 600
Current Mailing Address Current Street Address
Monroe NC 28112 _ Monroe NC 28112
City State Zip City State Zip

Telephone [phone] Fax Number [phone]
2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address of
the designated North Carolina Agent:
N/A
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible Party
is a Corporation, give name and street address of the Registered Agent:
N/A
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
The above information is true and correct to the best of my knowledge and belief and was provided
by me under oath (This form must be signed by the Financially Responsible Person if an individual
or his attorney-in-fact, or if not an individual, by an officer, director, partner, or registered agent with
the authority to execute instruments for the Financially Responsible Person). I agree to provide
corrected information should there be any change in the information provided herein.
John Shutak, P.E. CIP Program Manager
Type or print name Title or Authority
-7//s/ ,
Sig ure Date
I, � r 1- . h l.z hev' , a Notary Public of the County of toilor,
State of North Carolina, hereby certify that fl ��f 1 u' a 1< appeared
personally before me this day and being duly sworn acknowledged that the above form was executed
by him.
Witness my hand and notarial seal, this / *i day of td Y , 20 00
ee eeaeav0000ard ��'��O
1 " ✓ten
4 e
Notarci
Seale C/ G s �'
_��` `� BL1 Jo My commission expires r [
•
`"CO Li
J' ee,`';,,e`,`a�a